1
What impact do structured educational sessions to increase emotional intelligence have
on medical students?
Gemma Cherry1, Ian Fletcher
2, Nigel Shaw
3, Helen O’Sullivan
1
1 Centre for Excellence in Evidence Based Teaching and Learning (CEEBLT), School of
Medical Education, University of Liverpool
2 Division of Clinical Psychology, University of Liverpool, Whelan Building, Brownlow Hill,
Liverpool L69 3GB
3 Liverpool Women’s Hospital, Crown Street, Liverpool
Correspondence to:
Gemma Cherry
Centre for Excellence in Evidence Based Teaching and Learning (CEEBLT)
School of Medical Education
Cedar House
University of Liverpool email [email protected]
Brownlow Hill
Liverpool, L69 3GB
2
Abstract
Background: Emotional Intelligence (EI) has been defined as “a type of social intelligence
that involves the ability to monitor one’s own and other’s emotions, to discriminate among
them, and to use this information to guide one’s own thinking and actions” (Salovey and
Mayer, 1990). It can be speculated that EI is related directly to the competency of
interpersonal and communication skills, and is important in the assessment and training of
medical undergraduates.
Aim: This review aimed to determine the impact of structured educational interventions on
the emotional intelligence of medical students
Methods: We systematically searched 14 electronic databases and hand searched high yield
journals. We looked at changes in emotional intelligence and related behaviour of medical
students, assessed using Kirkpatrick’s hierarchy, provided they could be related directly to
the content of the educational intervention.
Results: A total of 1947 articles were reviewed, of which 14 articles met the inclusion
criteria.
Conclusions: The use of simulated patients is beneficial in improving EI when introduced in
interventions later rather than earlier in students’ undergraduate medical education.
Regardless of duration of intervention, interventions have the best effects when delivered: 1)
over a short space of time; 2) to students later in their undergraduate education and; 3) to
female students. This should be taken into account when designing and delivering
interventions. Emphasising the importance of empathetic qualities, such as empathetic
communication style should be made explicit during teaching.
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Practice points
1. The use of simulated patients is beneficial in improving emotional intelligence when
introduced in interventions later in the course rather than earlier (i.e. in final year
students rather than first year students)
2. Regardless of duration of intervention, interventions have the best effects when
delivered over a short space of time, i.e. less than a month.
3. Interventions have the most positive effect when given to students later in their
undergraduate education, for example in their final or penultimate years
4. Emphasising the importance of empathetic qualities, such as empathetic
communication style generally improves EI, therefore these qualities should be made
explicit during teaching.
5. Interventions generally have the most positive effect on females rather than males,
which should be taken into account when designing and delivering interventions.
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Executive Summary
Background and context: Emotional Intelligence (EI) is a type of social intelligence It
consists of the ability to manage your own and other’s emotions in your day to day life, and
to use this information to inform your thinking and behaviour. It is a characteristic, similar to
other constructs such as reasoning, thinking and conscientiousness, which can be used to
differentiate between individuals. Research within medical education has suggested looking
at doctors’ EI to assess their levels of emotional competence when interacting with patients.
Other research found a relationship between the EI of medical students, and patient
satisfaction scores after their Objective Structured Clinical Examinations (OSCEs). It can be
speculated that EI is related directly to interpersonal and communication skills, and is
important in the assessment and training of medical undergraduates. It is therefore important
to assess if EI can be improved by targeted, structured educational interventions, as medical
students who have high EI may be better at responding to expressions of emotional distress
by patients than those with lower EI. We investigated this problem using a systematic review.
The aim of the review was to focus on if medical students may be taught to improve their EI,
using Best Evidence Medical Education (BEME) guidelines.
Review Methodology: An educational intervention was defined as a structured process
intended to improve medical students’ emotional intelligence or emotional development. Due
to the large amount of literature relating to this subject, some inclusion criteria were devised
as a means of narrowing the focus of the review. The inclusion criteria were that the
participants must be medical students, that the outcomes measured in studies must be related
to their EI or emotional development, that the studies must not be general review articles or
editorials, and that the studies must report interventions with content that is documentable
and repeatable, and run over a defined time period. 14 relevant health and educational
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databases were searched electronically, using multiple search terms to ensure that all relevant
material was captured. High yield journals and reference lists of included papers were hand
searched. 2419 studies were retrieved, producing 1947 once de-duplicated. The abstract of
each study was obtained, and looked at for relevance by 2 members of the team. Full-text
papers were obtained for 36 studies, of which 14 studies were identified as fulfilling all
inclusion criteria and were suitable for inclusion in review. Due to the variety in outcome
measures reported, the studies were grouped by outcome according to Kirkpatrick’s 1967
model of hierarchical outcomes at four levels. In order to assess the quality of the studies, a
categorical method of assessment was used to incorporate both study design and quality of
results. No study was excluded based solely on quality score, although this was considered in
the analysis of studies. Relevant information was extracted from each paper by a member of
the review team, using a tailored coding sheet.
Implications for practice: Following this systematic review, several conclusions for practice
were found. Overall, educational interventions to improve EI in medical students have a
small, positive effect on attitudes and knowledge. The use of simulated patients is beneficial
in improving EI when introduced in interventions later rather than earlier in students’
undergraduate medical education. Regardless of duration of intervention, interventions have
the best effects when delivered: 1) over a short space of time; 2) to students later in their
undergraduate education and; 3) to female students. This should be taken into account when
designing and delivering interventions. Emphasising the importance of empathetic qualities,
such as empathetic communication style should be made explicit during teaching.
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Introduction
What is emotional intelligence?
In addition to research into psychometric intelligence, interest in assessing and measuring
non-cognitive, socially competent behaviour (Moss and Hunt, 1927) has been ongoing since
the early 20th
century. The term social intelligence was used to describe the skill of
understanding and managing other people to facilitate social interaction processes
(Thorndike, 1920, Hunt, 1928). This concept received limited support and research interest
until 1990, when it was re-named emotional intelligence (EI) by Mayer and Salovey (Salovey
and Mayer, 1990). They defined EI as “a type of social intelligence that involves the ability
to monitor one’s own and other’s emotions, to discriminate among them, and to use this
information to guide one’s own thinking and actions” (Salovey and Mayer, 1990).
In 1997, this definition was further developed by Mayer et al as “the ability to perceive
emotion, integrate emotion to facilitate thought, understand emotions, and to regulate
emotions to promote personal growth”. Davies et al. (Davies and Stankov, 1998) argued that
EI was an abstract concept, and proposed that EI refers to four salient constructs: appraisal
and expression of emotion in oneself; appraisal and recognition of emotion in others;
regulation of emotion in oneself; and the use of emotion to facilitate performance. Law et al.
(Law et al., 2004) further clarified the concept of EI by defining EI as an attribute separate
from the Big Five personality dimensions (Costa and McCrae, 1985) of openness,
conscientiousness, extraversion, agreeableness and neuroticism. He went on to say that EI is a
feature of intelligence, loosely proportional to general mental abilities, which increases with
age and past experiences, due to its developmental nature (Law et al., 2004).
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Description of main models of EI:
EI was conceptualised by Mayer and Salovey (Salovey and Mayer, 1990) as comprising three
major components:
1. The appraisal and expression of emotion in oneself and others.
2. The regulation of emotion in the self and others.
3. The utilization of emotion.
The first component encompasses the skills to perceive and correctly identify particular
emotions expressed either verbally and/ or non-verbally, and to provide socially adaptive
responses to others emotions e.g. empathy. The second aspect refers to moods which are
usually thought of as being less strong than emotions, although longer lasting. The capacity to
‘lift’ one’s own mood or others is clearly positive in many circumstances, and the third
component relates to employing emotions to achieve goals i.e. using ‘controlled aggression’
in sporting endeavours.
Three main models of EI have now been proposed (Spielberger, 2004): the ability model, the
mixed model and the trait model. The ability model, by Salovey and Mayer (Salovey and
Mayer, 1990), defines EI as a set of 4 distinct yet related abilities: perceiving emotions, using
emotions, understanding emotions and managing emotions. Mixed models include those
proposed by Goleman (Goleman, 1998) and Bar-On (1997). Goleman’s model (Goleman,
1998) views EI as a wide array of competencies and skills that drive managerial performance
with five dimensions that are categorised into two areas i.e. personal competence (self-
awareness, self-regulation, motivation) and social competence (empathy and social skills).
The Bar-On model (Bar-On, 1997) also has five dimensions: intrapersonal, interpersonal,
stress management, adaptability, and general mood which encompass mental abilities and a
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wide range of personal qualities, such as optimism, independence and happiness. Finally, the
trait model (Petrides et al., 2007) proposes that trait EI is “a constellation of emotion-related
self-perceptions located at the lower end of personality”, and this model comprises 15 facets
that range from adaptability to emotions and traits such as optimism. These models are
summarised in Table 1, below.
Table 1: Summary of the main models of EI
Mayer and
Salovey: Four-
branch Model of
EI
Perception of emotion (Branch 1)
Use of emotion to facilitate thinking (Branch 2)
Understanding of emotion (Branch 3)
Management of emotion (Branch 4)
Goleman’s Five
Dimensional
Model of EI
Self-awareness (Emotional Awareness, Accurate Self-
Assessment, Self-Confidence)
Self-regulation (Self-Control, Trustworthiness,
Conscientiousness, Adaptability, Innovation)
Motivation (Achievement Drive, Commitment, Initiative,
Optimism)
Empathy (Understanding Others, Developing Others, Service
Orientation, Leveraging Diversity, Political Awareness)
Social Skills (Influence, Communication, Conflict Management,
Leadership, Change Catalyst, Building Bonds, Collaboration
and Cooperation, Team Capabilities)
Bar-On’s EQ-i Intrapersonal (Self-Regard, Emotional Self-Awareness,
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Model of EI
Assertiveness, Independence, Self-Actualization)
Interpersonal (Empathy, Social Responsibility, Interpersonal
Relationship)
Stress Management (Stress Tolerance, Impulse Control)
Adaptability (Reality-Testing, Flexibility, Problem-Solving)
General Mood (Optimism, Happiness)
Petrides’ Trait
Model of EI
Adaptability
Assertiveness
Emotion perception (self and others), expression, management
(others) and regulation
Impulsiveness (low)
Relationships
Self-esteem and self-motivation
Social awareness
Stress management
Trait empathy, happiness and optimism
Measurement of Emotional Intelligence
The conceptualisation of EI results in implications for quantifying levels of EI, and measures
of EI generally fall into two categories- put simply, these are those requiring respondents to
answer questions about problem solving ability (the trait and mixed model approach), and
actually solve problems (the ability model approach). If EI can be classed as an ability, as
advocated by Mayer et al. (Mayer and Salovey, 1997), and seen in that respect to be similar
to general intelligence, then accurate and reliable measurement should be possible. Mayer et
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al. (Mayer et al., 2002) propose EI to be measured using the Mayer-Salovey-Caruso
Emotional Intelligence Test (MSCEIT), an ability based measure of EI, measuring abilities to
perceive, facilitate, understand and manage emotions in oneself and others, such as
recognition of emotion in faces. When scored, the MSCEIT produces fifteen main scores: the
total EI score (or Quotient, EIQ), two Area scores, four Branch scores and eight Task scores.
In order for meaningful data interpretation, the participants’ raw scores are converted by the
test publishers, based on either expert or consensus scoring of items. Evidence for the scale’s
validity has been obtained through examinations of its correlation with related scales and
with outcomes theoretically linked to EI(Mayer et al., 2002), yet the MSCEIT has been
criticised for being a knowledge test, rather than a true test of ability.
It has been suggested, by Zeidner et al. (Zeidner et al., 2008), that ability based tests of
emotional intelligence (such as the MSCEIT, particularly the Branch of Understanding
Emotion) measure emotional knowledge, which in turn is related to crystallised intelligence
(Ciarrochi et al., 2000).
The scales linked to the other models in Table 1 are self-report scales measuring dispositional
tendencies, so are more similar to personality scales. Bar-On and Goleman’s model are both
mixed models of EI, thereby adding to the uncertainty of measurement, as both conceptualise
EI as a mixture of traits and abilities. Bar-On proposes measurement of EI using the Bar-On
Emotional Quotient Inventory (or EQ-i) (Bar-On, 1997), a 133 item self-report measure with
a five-point Likert response scale, with EI defined as “an array of non-cognitive capabilities,
competencies and skills that influence one’s ability to succeed in coping with environmental
demands and pressures”. By its very definition, a mixed model of EI, cannot be measured
with a self-report measure, as traits cannot be measured objectively by self-report alone.
Similarly, objective measurement of EI would not be possible if EI is conceptualised as a
trait, as proposed by Petrides et al. (Petrides et al., 2007). The validity of emotional
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intelligence measures is well summarised by Zeidner et al. (Zeidner et al., 2008), that states
that self-report measures, such as the Bar-On EQ-i, have shown to correlate little to none with
traditional measures of intelligence (Davies et al., 1998), and correlate strongly with several
personality traits (Matthews et al., 2002). From this, it can be speculated that trait and mixed
models have questionable discriminant validity (Zeidner et al., 2008). There is also a low
correlation between different measures of EI, generally ranging from between 0.20 to 0.30;
Perez et al. (Pérez et al., 2005) propose that trait EI instruments instead measure emotional
self-efficacy, whereas ability measures measure cognitive-emotional ability.
Each model of EI proposes its own measurement method, thus creating difficulty in
comparing results from one model to results from another However, whilst there are four
definite, separate models of EI, there are some common components across the two mixed
models and the trait model. For instance, the areas of personal competence in the Goleman
model map onto the intrapersonal, stress management and adaptability dimensions of Bar-
On’s model, and various facets of the Petrides model e.g. impulsiveness, self-esteem etc.
Similarly, empathy is mentioned in each model (being conceptualised as trait empathy by
Petrides et al. (Petrides et al., 2007), as is the importance of emotional awareness (labelled
emotional self-awareness by Bar-On, and emotion perception (self and others) by Petrides et
al. (Petrides et al., 2007). Adaptability is also named in each model, falling under the heading
of Self-Regulation in Goleman et al.’s model. In addition, stress management is named by
both Bar-On and Petrides et al. Table 1 shows in detail the facets of each model, along with a
brief expansion of these facets. Using the definition that EI is “a type of social intelligence
that involves the ability to monitor one’s own and other’s emotions, to discriminate among
them, and to use this information to guide one’s own thinking and actions” (Salovey and
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Mayer, 1990), it is apparent that many aspects of behaviour map onto this construct e.g.
empathy and responsiveness towards patients’ views in consultations. It is therefore
important not to limit outcome measures when considering studies that may look at EI in
differing ways.
It is important to conceptualise what is being discussed in this review when ‘emotional
intelligence’ is referred to, as there are various different definitions, models and measurement
methods of EI (as discussed previously) which can lead to confusion as to the underlying
principles.
Emotional intelligence, put plainly, is a type of social intelligence. It consists of the ability to
manage your own and other’s emotions in your day to day life, and to use this information to
inform your thinking and behaviour. It is a characteristic, similar to other constructs such as
reasoning, thinking and conscientiousness, which can be used to differentiate between
individuals.
In this review, EI is defined as the characteristics that best equip an individual for successful
social and personal interactions, and EI is considered to contain several components which
we feel are necessary aspects of this. These include: empathy (broadly be defined as the
capability to share another’s emotions and feelings); mindfulness (broadly defined as an
awareness of one’s body functions, feelings and consciousness); empathetic communication
style (the ability communicate appropriate reactions to others’ emotions and feelings);
compassion (defined as awareness of the suffering of others, and a desire to relieve it); and
sensitivity (defined as the ability to react appropriately to the emotions or situations of other
people).
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EI within medical education
Historically, to maximise the objectivity of treatment, doctors have been traditionally advised
to maintain a professional distance from their patients. The nature of doctors’ work is such
that they work in a fluctuating, unpredictable climate, with collaboration and team working
regularly required to solve diverse problems.
However, there exists a recent shift towards recognition of the importance of emotional
intelligence within medical education (Lewis et al., 2005), particularly as an attribute in
fostering the patient-doctor relationship. One facet of this relationship, effective patient-
provider communication (PPC), can be conceptualised as an interaction whereby a doctor
allows medical consultations to be patient led. This allows for patient autonomy, a concept
which may lead to more effective treatment adherence and better outcomes for patient.
Heralded throughout medical education research, this ‘patient centred approach’ has been
identified as a central value in medical communication. Multiple studies of practicing doctors
have investigated and identified the factors associated with effective communication
(Maguire and Pitceathly, 2002). For example, Giron et al. (Giron et al., 1998) found that
doctors’ ability to listen and ask psychosocially relevant questions is associated with
identification of the patients’ emotional problems, independent of the age, gender and
experience of the doctor in question.
The General Medical Council (2009) sets out effective communication with patients and
colleagues as a key outcome for graduates in Tomorrow’s Doctors. In addition, doctors’
interpersonal communication skills have been identified as one of six areas of professional
competence for doctors by the Accreditation Council for Graduate Medical Education
(AACM) in the USA, with EI included as an assessment item under moral/affective
dimension (Epstein and Hundert, 2002). The importance of effective communication for
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practicing physicians has been identified in other national codes such as CANMED in
Canada (which groups communication under one of the seven groups of competencies for
practicing physicians (2005)) and the Australian Medical Council (AMC).
It is apparent throughout the literature that predictors of effective patient-doctor relationships
are well researched, yet little research has assessed the association between EI and the
patient-doctor relationship. Research by Wagner et al. (Wagner et al., 2002) and Weng et al.
(Weng et al., 2008) found weak links between doctors’ EI and patient outcomes. Wagner et al
(2002) found only one subscale of EI related to higher patient education, the ‘happiness’
subscale of the Bar-On EQ-i whereas Weng et al. (Weng et al., 2008) found that doctors’ self
rated EI was not correlated with any variables related to patient trust by patients. More
research is needed to assess this relationship, both in undergraduate and postgraduate medical
professionals.
Guidelines about essential skills for medical graduates have been created by the medical
regulatory bodies, such as the GMC, the AACM, the AMC and CANMEDS. These
guidelines encompass intrapersonal, interpersonal and professional skills and attributes. As a
result, patient-centred skills are gaining increasing recognition as important aspects of
medical education curricula (Brown and Bylund, 2008, 2009). Recently, literature has begun
to assess the importance of developing EI in medical students prior to graduation (McMullen,
2003). However, there exists a debate in the literature as to the impact of EI training in
medical students. Kasman et al. (Kasman et al., 2003) have argued that it is important to gain
a fuller understanding of patients’ emotional situations before the improvement of emotional
‘competencies’.
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It has been indicated that training in communication skills leads to a decrease in anxiety by
students regarding communication with patients, although anxiety still remains when faced
with patients who are crying or in emotional distress (Hajek et al., 2000). It is therefore
important to consider how communication skills training, in particular the role of emotional
intelligence and empathy training, is translated and applied by medical students. Austin et al.
(Austin et al., 2005) found that medical students who had higher emotional intelligence
reported more positive feelings about a communication skills exercise, and other studies have
reported similar findings.
Re-conceptualisation of EI as the “sensitive and intelligent problem-solving activities
emerging from deliberate, structured group learning” (Lewis et al., 2005) may therefore make
it more relevant to undergraduate and postgraduate medical education.
Research within medical education has suggested using EI as a means of assessing levels of
professional competence within the affective/moral dimension (Epstein and Hundert, 2002).
Stratton et al. (Stratton et al., 2005) found that facets of EI were related to simulated patient
satisfaction scores in Objective Structured Clinical Examinations (OSCEs), indicating the
importance of evaluating EI training within medical education research.
There exists a large body of literature pertaining to interventions to improve EI in medical
students, despite research indicating that effective training in the ability to manage emotions
is difficult within undergraduate medical education (Sade et al., 1985).
Previous work into the teaching of interviewing skills (Evans et al., 1989) indicates that some
skills are easily taught, whilst other skills, based on higher level understanding, are not.
‘Structural’ interviewing skills (such as use of wide ranging questions and clear
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communication) appear to be easily ascertained, whilst skills such as the use of empathy in
responding to distressed patients do not.
Using this framework, it can be speculated that EI related directly to the competency of
interpersonal and communication skills is important in the assessment and training of medical
undergraduates and practicing healthcare professionals. Initially, these skills may seem a
reflection of personality, yet accurate management and reading of emotions is necessary to
learn and demonstrate these skills properly.
Researchers have begun to assess the importance of interpersonal EI (such as empathy) in
patient encounters, with increasing recognition of the importance of intrapersonal EI,
particularly when dealing with stress. EI, as a construct, can easily be mapped onto Hilton
and Slotnick’s (Hilton and Slotnick, 2005) six domains of professionalism, with intrapersonal
skills reflecting the personal, or intrinsic, attributes of professionals, and interpersonal skills
reflecting the co-operative attributes of professionals. The benefit, therefore, of recruiting
emotionally intelligent individuals to undertake undergraduate training is apparent.
However, medical schools receive large amounts of applicants each year, all with uniformly
high academic achievements. With each medical student in the UK currently costing
approximately £200000 to train (Brown and Bylund, 2008), it is essential that selection
methods are robust and reflect the skills and attributes laid out by regulatory bodies. In the
USA, assessment of EI has been integrated as part of the selection process in some medical
schools, in an attempt to consider competency in interpersonal skills (Carrothers et al., 2000,
Elam, 2000). Despite the use of EI as a selection measure, at present little research has been
conducted on medical students’ EI. There is a growing need to thoroughly understand the role
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of EI in being an effective physician, in order to ensure that the admissions process selects
the right type of student.
The use of EI within a medical setting was questioned by Lewis et al. (Lewis et al., 2005),
with concerns being raised about the construct validity and psychometric properties of scales.
From the research, the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT)
(Mayer et al., 2002), an ability based assessment of EI, has been suggested as a consistent and
preferred measure of EI (Spector, 2005), that has a strong internal validity (Daus and
Ashkanasy, 2005).
It is evident that more research is needed to assess the role of EI, if any, within the medical
school selection process.
A systematic review has already been undertaken evaluating emotion skills training in
medical students (Sattersfield and Hughes, 2007), and this review builds on this work by
assessing outcomes of studies at several levels. This has been done in line with Best Evidence
Medical Education guidelines, and used Kirkpatrick’s 1967 model of hierarchical outcomes
to assess the effectiveness of educational interventions.
This systematic review therefore aimed to assess the impact of educational sessions to
improve EI in medical students, and aimed to give a theoretical background to the study of
behavioural change with regards to facets of EI. The present selection process is based on
cognitive ability alone, therefore it is be valuable to consider methods of improving
emotional intelligence in medical students and their effectiveness, particularly given the
research suggesting the importance of EI in medicine.
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Objectives
The objective of this review was to inform medical and healthcare professionals, trainers,
educationalists and educational researchers of the impact of structured training sessions to
improve emotional intelligence medical students. To evaluate this, we looked at changes in
the emotional development of medical students. Please see below for a more detailed
summary of outcome measures considered.
Review Question
Following in-group discussion, and feedback from the BEME steering committee, we
addressed the following review question:
What impact do structured educational sessions to increase emotional intelligence have on
medical students?
In addition, we also explored the following questions:
What are the effects of individual features of emotional intelligence training courses
on the behaviour of medical students?
What features characterise the emotional intelligence educational interventions?
What are the methodological strengths and weaknesses of the reported studies?
What are the implications of this review for service delivery, the teacher or trainer, the
medical education researcher and for ongoing research in this area?
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The review followed similar methodology to that used in a previously competed BEME
systematic review by some members of the group (Cherry et al., 2010).
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Review Methodology
Group Formation
A Topic Review Group (TRG) was formed comprising members of the Centre for Excellence
in Evidence Based Learning and Teaching (CEEBLT) at the University of Liverpool, the
Division of Clinical Psychology at the University of Liverpool and Mersey Deanery NHS
North West. This collaboration was selected to maximise expertise in both educational
research methodology and practising clinical experience. The TRG consisted of one
practising clinician, and three research active members of University staff.
Pilot Process
In order to prepare for the BEME systematic review, a pilot process was undertaken. This
was intended to determine the scope of the review, size of background literature, to refine the
review question and to determine if adaptation of the BEME Coding Sheet
(www.bemecollaboration.org/) would be suitable for use in the review.
Preliminary literature search
A scoping literature search was carried out to determine the size of background literature
pertaining to the review topic and to develop a potential, encompassing search strategy for
use in the final electronic literature searches.
This search was undertaken in July 2009, across Medline. Medline was chosen as it was
expected that Medline would have the largest body of literature relating to emotional
intelligence and the most relevant publications. Ovid Medline was used to determine MeSH
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search terms, and subject headings of relevant articles were examined to further develop the
search strategy.
A total of 2012 articles were retrieved as a result of this search, of which the first 200 were
screened for eligibility by the lead reviewer. It was apparent that the search strategy needed
refinement, and as a result a new search strategy was established and piloted. The new
strategy incorporated key phrases and additional subject headings found by examination of
relevant studies, and when piloted yielded 1947 studies. This strategy is summarised on the
BEME website (www.bemecollaboration.org/), and forms the basis of the search used in the
final review search. Following this search, two reviewers from the project reviewed the titles
and abstracts of the first 200 of the 1947 articles identified by the search. This enabled
confirmation that the lead reviewer had an appropriate balance of sensitivity and specificity
for relevant evidence which could not be improved by second-screening, and that this
researcher alone was able to select articles for further consideration from the main search.
Preliminary pilot of coding sheet
Members of the TRG met to discuss the suitability of the BEME Coding Sheet by piloting it
on a number of studies fulfilling the inclusion criteria for review. It became apparent that
there was enormous diversity in reporting style and details, and it therefore would not be
appropriate at this stage to produce a simple categorical tool to extract data. A more
comprehensive sheet was required, with more flexibility to report data as presented. A second
coding sheet was devised with free-text reporting boxes for this purpose. This is provided on
the BEME website (www.bemecollaboration.org/).
The following inclusion and exclusion criteria were used:
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Types of intervention
An educational intervention to improve emotional intelligence was, for the purpose of this
review, defined as a structured educational process intended to increase, improve or enhance
the performance of the recipients with regards to the assessment of competence in perceived
improvements in health or well being of their future patients. Interventions considered for this
review included, but were not limited to: courses; lectures; simulations; small group learning
session(s); e-learning, curriculum-based learning; shadowing / mentoring; workshops and
learning through educational material such as media, posters, handouts and other paper
material.
Interventions must have been both structured and educational in their nature to be included in
this review.
Types of participants
This review focuses on the delivery of educational interventions relating to the emotional
intelligence of medical students. Participants were any students undertaking undergraduate
medical training.
It was deemed likely that the effectiveness of educational interventions targeting doctors
would be different to those targeting solely medical students. Given that the differing
programmes to target medical students were already diverse in their delivery, it was agreed
by the TRG that adding another comparator would complicate the report. All studies that did
not focus on medical students were therefore excluded. Where studies had focused both on
educational interventions delivered to doctors and medical students, only the results of the
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medical student intervention were reported and considered. If results were not reported
separately from that of the doctors, the study was excluded.
Study design
Comparative (cross-sectional research, before and after studies, time series studies, non-
randomised trials, randomised controlled trials, group randomised trials, case control trials
and cohort studies) research designs were considered for inclusion. General review articles
and editorials were not considered but their reference lists were scanned to check all relevant
materials are included.
Comparators
Studies with comparators were considered for inclusion in the review, including but not
limited to use of a control group (e.g. students not receiving interventions), a differing
educational intervention and use of differing student groups.
Table 2: Inclusion Criteria
Inclusion criteria
Study design All study designs considered.
Studies conducted and published from 1990
onwards included.
Population Undergraduate medical students
OR
Contained medical students in addition to other
participants, for which results were recorded
separately.
Educational Intervention Content documentable and repeatable.
Interventions run over defined time period.
Interventions designed to change EI or
measures such as empathy, communication,
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compassion, mindfulness and sensitivity.
Comparator Any, including but not limited to use of a
control group, a differing educational
intervention and use of differing student groups.
Outcome Measures At least one outcome measure of EI.
Measured using Kirkpatrick’s hierarchy
(Kirkpatrick, 1967)
Table 3: Exclusion Criteria
Exclusion criteria
Study design Reviews and systematic reviews.
Studies published before 1990, or in which the
study period was prior to 1990.
Population All studies not focusing solely on medical
students, including studies using doctors as sole
participants.
Studies where results of inclusion medical
student groups could not be distinguished from
exclusion healthcare professional groups.
Educational Intervention Interventions not educational in content.
Comparator No exclusion criteria applied.
Outcome Measures No recorded outcome measure of EI
Outcome measures of study
For the purpose of the review we chose to define EI as the characteristics that best equip an
individual for successful social and personal interactions. These include empathy,
mindfulness, empathetic communication style, compassion and sensitivity when interacting
with simulated or real patients. Throughout this review, these outcome measures were
referred to under the umbrella term of ‘emotional intelligence’ Models of EI propose
additional components, such as adaptability and self-management (Bar-On, 1997), which we
agree are important components of successful interactions. However, for the purpose of this
25
review we chose to define EI and expand this definition only to include qualities directly
related to emotional management and interaction, which can be clearly conceptualised in the
literature.
The outcome measures were informed by our pilot review. Initially, only the term “emotional
intelligence” was considered, but this narrowed the scope of the review too greatly, and it
was felt that expanding the term ‘emotional intelligence’ would provide a more complex and
in-depth overview of the effectiveness of interventions to improve EI in medical students. It
is possible that such an additive view may lead to difficulty in interpretation of study
findings, but due to the scarcity of published literature on interventions to specifically
improve emotional intelligence, a narrower focus would yield little data. The literature
demonstrates fluidity to the definition and measurement of emotional intelligence, therefore
using a more expansive search in this review means that findings may still be informative,
even if definitions of EI change.
For the purpose of this review, we chose not to limit our findings to one model, and therefore
definition and method of measurement, of EI. This was important, particularly as EI was first
conceptualised only in 1990, and the definition of EI is regularly being modified as new
models and research becomes published. Both self-report measures of outcomes, such as EI
scales, and observed change in outcome measures were considered.
Assessment of outcome measures
26
These will be based on modified Kirkpatrick’s 1967 model of hierarchical outcomes at four
levels, as illustrated in Table 4. Additional predetermined or secondary outcome measures
were also accepted and recorded. Kirkpatrick’s hierarchy has been selected to provide a more
comprehensive evaluation, in order to inform this review’s development. This model has
been used by other BEME review groups (Issenberg et al., 2005) and, once modified, fits the
outcome measures of the review.
27
Level 1: Reaction
This covers learner’s views on
the delivery and content of the
educational intervention. This
may take the form of verbal or
written feedback immediately
after the delivery of the
intervention, and includes
learner’s views on presentation,
organisation, content, teaching
methods, time-tabling, materials
used and quality of teaching.
Level 2a: Modification of
attitudes and perceptions
This relates to any changes in
reciprocal attitudes or
perceptions between participant
groups. This includes any
changes in perceptions or
attitudes by participants
towards the value and/or use of
the taught approach to caring
for patients, and their condition,
circumstances, care and
treatment.
Level 2b: Acquisition of
knowledge and skills
For knowledge, this relates to
the acquisition of concepts,
procedures and principles of
emotional intelligence as a
direct result of the delivery of
the educational intervention.
For skills, this relates to the
acquisition of
thinking/problem-solving,
psychomotor and social skills
linked to emotional intelligence
as a direct result of the delivery
of the educational intervention.
Table 4
Kirkpatrick’s
Hierarchy(Kirkpatrick, 1967)
Level 3: Behavioural change
This relates to the transfer of
emotional intelligence to the
workplace, such as support for
change in behaviour in the
workplace, or willingness of
learners to apply knowledge
and skills about emotional
intelligence, obtained as a direct
result of the delivery of the
educational intervention, to
their practice style.
Level 4a: Change in
organisational practice
This relates to wider changes in
the organisation/delivery of
care, attributable to the delivery
of an education intervention.
These changes may be financial
or organisational.
Level 4b: Benefits to patients /
clients, families and
communities
This relates to any
improvements in the health and
well being of patients as a direct
result of the delivery of an
educational intervention. Where
possible, objectively measured
or self reported outcomes will
be used. These outcomes will
be determined by the literature
found.
Table 4
Kirkpatrick’s
Hierarchy(Kirkpatrick, 1967)
28
Search Strategy
A comprehensive search was conducted to determine the body of literature pertaining to the
review question across all sources relevant to healthcare education and best practise in an
undergraduate and clinical context. This search was divided into two sections - an electronic
search of relevant health and educational databases, and augmentation of this search using
various methods. These will be summarised in detail below.
Searching of literature base
A comprehensive electronic search was carried out in November 2009.
In total, 14 electronic databases were searched. These were chosen to span clinical and
educational databases, and are listed on the BEME website (www.bemecollaboration.org/),
along with the individual search strategies used for each. The initial, piloted strategy pertains
to Medline, and was adapted for each database to reflect minor modifications specific to their
vocabulary or search terms. Natural language terms were derived for those databases that did
not recognise MeSH search headings, such as the National Research Register and Web of
Science, and were based on synonyms of a combination of three relevant components: EI,
medical students and educational interventions.
Medline records were substituted for duplicated records from other databases when identified
due to their standardisation and level of detail. A total of 2419 studies were retrieved,
producing 1947 studies once de-duplicated. Only original research findings were included in
the search - editorials and essays were excluded.
A two-stage process was employed to retrieve relevant articles. The lead reviewer (GC) and
one other member of the review team initially screened all titles and abstracts, and eliminated
all studies not relating to educational interventions to improve EI. Any discrepancies were
29
discussed with another member of the review team, and a decision was reached. This resulted
in 36 studies for which full text was obtained for all, 1.8% of the initial cohort.
A subsequent hand search of high yield journals was carried out (see the BEME website
(www.bemecollaboration.org/)for full list of journals hand searched), followed by a search of
reference lists of all full-text studies, and hand search of the researcher’s own files. This
yielded a subsequent 11 studies, and cross-checking with the results of the electronic
searching confirmed receipt of these studies in the initial electronic cohort.
These 36 full-text studies were independently reviewed by two members of the review team,
seeking consensus from a third member when opinion as to suitability was divided. From
this, 15 studies were identified as fulfilling all inclusion criteria and therefore suitable for
inclusion in the review.
It cannot be said for certain that all relevant, high quality published material was obtained
through the combination of electronic searching and hand searching of journals selected as
the most likely robust publishers of related material. However, knowledge within the field of
emotional intelligence, together with continued monitoring of evidence bases has led us to
conclude that this review will encompass as much published material as possible to answer
the review question based on the best available evidence, using systematic processes.
Quality assessment
Each full-text paper was read and quality assessed. We used a quality assessment checklist to
supplement the coding sheet. A categorical method of assessment was used to incorporate
both study design and quality of results.
30
This method of assessment yielded a quality assessment score for each paper from between 2
and 9. No study was excluded from the review based solely on quality assessment score. The
tool used is summarised on the BEME website (www.bemecollaboration.org/).
Coding
Each full text paper was coded by a member of the review team. A random sample of 20% of
studies was doubly coded to ensure that appropriate, consistent and matching data were
collected. Data collected were entered into Microsoft Excel.
31
Review analysis
Description of studies
Fourteen studies met the criteria for inclusion in this review. Included studies are summarised
in tables 5 and 6. Of these studies, five were conducted in the USA (Henry-Tillman et al.,
2008, Knight et al., 1992, Shapiro et al., 2004, Shapiro et al., 2005), four were conducted in
Australia (Evans et al., 1993, Farnill et al., 1997, Moorhead and Winefield, 1991, Winefield
and Chur-Hanswn, 2000), two were conducted in the UK(Fletcher et al., 2009, Lancaster et
al., 2002), and one each in Canada (Craig, 1992), Sweden (Holm and Aspegren, 1999), Spain
(Fernandez-Olano et al., 2008) and Turkey (Harlak et al., 2008).
Five studies used first year medical students as participants (Craig, 1992, Harlak et al., 2008,
Henry-Tillman et al., 2008, Shapiro et al., 2004, Winefield and Chur-Hanswn, 2000), four
used fourth year medical students (Evans et al., 1993, Knight et al., 1992, Lancaster et al.,
2002, Moorhead and Winefield, 1991), two studies used second year medical students
(Farnill et al., 1997, Fernandez-Olano et al., 2008), one study used third and fourth year
medical students (Shapiro et al., 2005), and one each used third year medical students
(Fletcher et al., 2009) and students in a mixture of years (Holm and Aspegren, 1999).
32
For the purpose of the review we chose to define EI as the characteristics that best equip an
individual for successful social and personal interactions. These include empathy (broadly
defined as the capability to share another’s emotions and feelings); mindfulness (broadly
defined as an awareness of one’s body functions, feelings and consciousness); empathetic
communication style (the ability communicate appropriate reactions to others’ emotions and
feelings); compassion (defined as awareness of the suffering of others, and a desire to relieve
it); and sensitivity (defined as the ability to react appropriately to the emotions or situations
of other people). Throughout this review, these outcome measures were referred to under the
umbrella term of ‘emotional intelligence’.
Assessment of outcome measures was based on Kirkpatrick’s modified 1967 model of
hierarchical outcomes. This model evaluates the impact of an educational intervention using
four levels: Level 1(Reaction of the learner to the delivery and content of the educational
intervention); Level 2a (Modification of attitudes and perceptions as a result of the
intervention) and Level 2b (Acquisition of knowledge and skills as a result of the
intervention); Level 3 (Behavioural change); Level 4a (Change in organisational practice)
and Level 4b (Benefits to patients / clients, families and communities). Studies reporting only
Kirkpatrick level 1 (reaction to intervention) were excluded (see the BEME website
(www.bemecollaboration.org/) for excluded studies). As participants were students, no
assessment considered change in organisational practice or benefits to patients / clients,
families and communities (level 4).
Studies using level 2a as an outcome measure
33
Thirteen of the fourteen studies (Craig, 1992, Evans et al., 1993, Farnill et al., 1997,
Fernandez-Olano et al., 2008, Fletcher et al., 2009, Harlak et al., 2008, Henry-Tillman et al.,
2008, Knight et al., 1992, Lancaster et al., 2002, Moorhead and Winefield, 1991, Shapiro et
al., 2004, Shapiro et al., 2005, Winefield and Chur-Hanswn, 2000) measured a change in
medical students’ attitudes with regards to EI (level 2a). Of these, four used in-house
questionnaires to measure change in self-reported EI, and the remainder used validated
questionnaires together with either focus groups, written evaluations with debriefing sessions
or nominal group technique- free text questions or focus groups. The characteristics and
results of these studies are summarised in Table 2.
The combined results of these level 2a studies suggest that interventions that aim to improve
attitudes around EI/empathy seem to benefit females more than males, as five of the thirteen
studies report that females increased significantly more than males (Fernandez-Olano et al.,
2008, Harlak et al., 2008, Holm and Aspegren, 1999, Shapiro et al., 2004, Winefield and
Chur-Hanswn, 2000). Interventions that are introduced later in the course appear to have a
more beneficial effect than those introduced with early year students. Similarly, the use of
simulated patients appears to be more beneficial to later rather than early year students.
Several interventions emphasised empathetic behaviour, particularly when communicating,
and these interventions appeared to have a positive effect on attitude change.
Studies using level 3 as an outcome
Three studies measured observation of behavioural change in medical students’ EI (level 3),
and all used coding tools to rate EI from videotaped simulated scenarios. The characteristics
and results of these studies are described in Table 2.
The combined results of these level 3 studies indicate that there may be a decline in
EI/empathy over the course of undergraduate medical education. Interventions such as those
34
reported above may not be effective in improving and sustaining EI over the course.
Interpreting the results of these interventions is difficult, as they are not clearly defined.
However, interventions seem to be most effective when targeted at students in later years,
indicating that they may have more of an effect on more mature students. However, it is not
clear if they are consistently effective.
35
Outcome measures
Table 5- Description of included studies
Author Focus of
intervention Main outcome measure
Intervention
duration/frequency Main findings Other notes
Quality
score
Craig
1992
Effective
communication
and empathy
In-house checklist of
videotaped interviews
30 hours, freq. not
stated
Both groups demonstrated a significant
decline in empathy scores in third and
fourth year (p=0.001) from first year.
Compared
intervention group
with control group
longitudinally
6
Evans
1993
Effective
communication
and empathy
History-taking rating scale
(Evans et al., 1989)- rating
of videoed OSCEs
Not stated
No statistically significant difference in
empathy scores between participants who
had received communication skills
training and those who had not. Cohort 1
(no training): 2.7/4, Cohort 2 (training)
2.6/4. p=0.471
Compared Cohort 1
(no training) with
Cohort 2
(communication
skills training)
7
Farnill
1997
Psychosocial
interviewing
techniques, with
empathy
outcomes:
i) Volunteers completed
questionnaire (not
standard). Ii) Students
completed evaluation of
own performance
questionnaire (not
standard). Iii) Videotaped
interviews rated by
psychologist experienced in
comm. skill teaching (not
standardised). "empathetic
responding to content and
7 months- 16
sessions of 1 hour
Students were significantly more
competent in their second interview than
in their first (based on video ratings,
p<0.01), Scale assessing facilitation of
emotional expression showed no
improvement (rated by video tape
analysis) although students rated
themselves are more competent than pre-
intervention (pre intervention rating 2.7/5,
post intervention rating 3.7/5). No real
change in volunteers’ ratings of
empathetic responding (2.8/5 pre, 3.0/5
7
36
feeling" post).
Fernand
ez Olano
2008
Empathy Jefferson Scale of
Physician Empathy
25 hours- 5 days of 5
hour sessions
Experimental group significantly
increased in empathy (p<0.02), from
120.5 (9.1) to 124.5 (7.58). Control group
also significantly increased (p<0.02), from
118.4 (3.1) to 119.9 (3.7) but ended with
lower mean than experimental group.
Data taken from students only.
6
Fletcher
2009
Emotional
intelligence Bar-On EQ-i
7 months- once
monthly for 4 hours
Statistically significant difference
between groups post intervention but not
at baseline. Intervention group scored
significantly higher on EQ-i post
intervention.
5
Harlak
2008
Empathy and
communication
skills
Communication Skills
Attitudes Scale (CSAS) and
Empathic Tendencies Scale
(ETS)
1 academic year (30
hours)- freq. not
stated
In pre test, 49% had positive attitudes
towards communication skills (CS)
learning (grouped as PAG, and remainder
as NAG), and 59% had higher empathic
tendencies (grouped as HEG, and
remainder as LEG). Post intervention,
PAG had significantly decreased attitudes
towards empathy, but no change in NAG.
In HEG, empathy scores did not change
significantly, but empathic tendency in
LEG significantly increased. Females had
higher mean scores than males in CSAS
and ETS pre and post tests.
7
37
Henry
Tillman
2002
Empathy
Small group reflection. 13
item survey measuring
knowledge of empathic
communication techniques
administered pre and post
intervention
13 afternoons
Focus group results: "most said yes when
asked if they had developed empathy for
the patient".
No statistically significant differences in
pre and post test of empathy (but
reportedly due to high levels at pre test)
7
Holm
1999 Empathy Affect Reading Scale Not stated
Hospital factors accounted for significant
proportion of variance. Students in 6th
term had significantly higher score than
students in the 1st term. In 8th term scores
differed between hospitals. PBL hospital
had no difference in scores between 8th
term and 6th term students, but traditional
teaching hospital 8th term students had
significantly lower scores than 6th term
students.
Different hospital
placements
compared in 8th
term. Compared
students from
different years
5
Knight
1992
Awareness,
sensitivity and
clinical skills in
dealing with the
terminally ill
In-house questionnaire 16 hours- 4 half days
Statistically significant increases pre to
post intervention in 8 of the 9 items
concerning hospice concepts. Changes in
attitudes positively in 4 of the 7 items
concerning hospice rotation. Statistically
significant changes in 5 of the 7 items
concerning palliative care.
7
Lancaste
r 2002 Empathy
Nominal group technique-
free text responses to
questions, focus group,
axial coding of responses
4 weeks- 13 seminars
of 2 hours, plus trips
to theatre and
museums and
individual tutorials
Reported that they had increased empathy
for patients, increased interpersonal skills,
reduced presumption towards patients,
empathy for other medical professionals
No detail about
numbers of
participants or
baseline measures
8
38
Moorhe
ad 1991
Improving
counselling,
interpersonal
and history
taking skills
Empathy Rating Scale
(ERS)
1 week (3 hours, then
1.5 hours, then 10
hours)
No statistically significant increase in
individual empathy scores from pre to
post test (average scores 12.6 and 12.8
respectively)
7
Shapiro
2004
Empathy and
attitudes
Empathy Construct Rating
Scale (ECRS), Balanced
Emotional Empathy Scale
(BEES), 9-item attitude
towards humanities
measure. Focus groups with
3 main questions.
8 sessions of 1 hour
Qualitative comments indicated students
had changed behaviour with regards to
looking at patient situations
Identical groups at baseline. Female
students, Asian students and student
planning to enter primary care showed
significantly more empathy post
intervention (BEES). Statistically
significant pre to post intervention
increases on attitudes towards humanities
scale and BEES
Students either
received immediate
participation in
intervention or were
wait-listed, forming
2 groups for
comparison
8
Shapiro
2005 Empathy In-house questionnaire Not stated
Third of students completing RASH notes
increased the likelihood that they would
express empathy for the patient. COLD
condition- 80% reported that the reading
increased some dimension of empathy for
the patient. Breast cancer poem- 30%
reported that poem increased their
empathy for patient moderately, and 60%
reported it increased their empathy a great
deal. Students reading 3 station specific
poems rated the poems' ability to increase
empathy significantly higher than their
helpfulness in influencing treatment.
Compared poems
and readings.
7
39
Winefiel
d 2000
Effective
communication
and empathy
10 item empathy scale by
Danish and Hauer
2 1.5 hour
workshops, a week
apart then 1 hour
interview
Pre intervention empathy score 9.97 (2.7).
Post intervention empathy score 14.44
(6.77). Significant improvement in
empathy scores (p<0.001). Females
scored significantly higher than males
post intervention (15.95 6.69 vs. 12.86
6.79, p<0.05). Neither sex improved more
than the other. 36.5% improved, 33.3%
improved a little and 30.2% did not
improve at all or decreased.
Assessment was part
of summative OSCE
8
40
Table 6- included studies continued
Author Location Participant group Mean age Number (final n/start n) Intervention duration/frequency
Craig 1992 Canada First year medical students - 26/31- 15 intervention, 11
control 30 hours, freq. not stated
Evans 1993 Australia
Fourth year medical students
(first clinical year)- two cohorts
studied
Cohort 1: 21.9,
Cohort 2: 22.3
Cohort 1: 49/54 Cohort 2:
45/52 Not stated
Farnill 1997 Australia Second year medical students 21.1 (18-33) 60 7 months- 16 sessions of 1 hour
Fernandez
Olano 2008 Spain
second year medical students
(plus residents)
137, 82 experimental, 55
control 25 hours- 5 days of 5 hour sessions
Fletcher 2009 UK Third year medical students
21.1 (2.0) -
intervention group.
24.4 (2.4)- control
group
70 , 25 intervention, 36
control 7 months- once monthly for 4 hours
Harlak 2008 Turkey First year medical students
59/70 1 academic year (30 hours)- freq. not
stated
Henry
Tillman 2002 USA First year medical students - 87 13 afternoons
Holm 1999 Sweden Medical students, in first, sixth
and eighth term - 240/286, Not stated
Knight 1992 USA Fourth year medical students
65/76 16 hours- 4 half days
Lancaster
2002 UK Fourth year medical students - Not stated
4 weeks- 13 seminars of 2 hours, plus
trips to theatre and museums and
individual tutorials
Moorhead
1991 Australia Fourth year medical students - 63
1 week (3 hours, then 1.5 hours, then
10 hours)
Shapiro 2004 USA First year medical students 23.4 (1.9) 22/92 8 sessions of 1 hour
Shapiro 2005 USA Third and fourth year medical
72/88 Not stated
41
students
Winefield
2000 Australia First year medical students 18.8 (1.9) 107/115
2 1.5 hour workshops, a week apart
then 1 hour interview
42
Review discussion
Summary of findings:
Fourteen studies were selected for inclusion in this review, a surprisingly low number given
the extensive research interest in the measurement and assessment of both professionalism
and emotional intelligence, including both interpersonal and intrapersonal dimensions of EI
(McMullen, 2003). The literature demonstrates fluidity to the definition and measurement of
emotional intelligence, therefore using a more expansive search in this review meant that
relevant papers were captured and findings are informative, even if definitions of EI change.
Great diversity was found in reporting styles and outcomes used, and despite the patient-
centred approach to medicine being widely accepted as central to efficient communication
(De Haes, 2006), eight of the fourteen included studies aimed to improve EI using no
reported patient contact, with mixed results. Overall, educational interventions to improve EI
in medical students were found to have a small, positive effect on attitudes and knowledge.
However, most studies considered Kirkpatrick level 2a, which may not be applicable to real-
life practice, and as such self-report measures may overestimate the impact of the
intervention.
Only three studies considered changes in medical students’ behaviour (level 3) as a result of
structured EI training courses (Craig, 1992, Evans et al., 1993, Holm and Aspegren, 1999),
and very little information as to the replicable details of the interventions were provided. No
transferrable and detailed descriptions were provided as to the use of, for example, printed
educational materials, demonstrations, small group teaching, lectures or online elements of
each intervention. It is therefore not possible from the small number of studies evaluating
behavioural change in medical students, and the sparsity of information reported to assess the
43
effects of individual features of emotional intelligence training courses on behavioural
change.
Overall, inconsistencies were evident in methodological reporting and quality, in the 14
studies included in this review. None of the studies reviewed provided an appropriate
framework for defining, measuring or understanding emotional intelligence within their
work. This resulted in the inclusion in this review of a wide range of EI proxy measures, thus
illustrates the problems caused by the broad definition of EI and related constructs within
medical education. Many definitions of EI have been proposed, including those by Mayer et
al., Goleman, Bar-On and Petrides. It has been suggested by Lewis et al. (Lewis et al., 2005)
that some facets of what is currently defined as “EI” may be relevant to medical education
due to the nature of doctors’ work; often problems are ill-structured, require collaborative
attention and team working, and occur in an uncertain landscape. If EI can be reframed as the
“sensitive and intelligent problem-solving activities emerging from deliberate, structured
group learning” (Lewis et al., 2005), then it is not difficult to see the relevance of EI to both
undergraduate and postgraduate medical education. However, this may mean that the term EI
means something different than that postulated by Mayer and Salovey in 1990, and modified
in 2000. Further work is needed to achieve clarity amongst researchers as to the true
definition of EI and how it should be measured.
No study used the same outcome measure as any other, illustrating the heterogeneity in
assessment measures available. It is therefore possible that some, if not all, outcome measures
selected by the authors of included studies may not be accurately mapping onto dimensions
of EI, but instead may be measuring manifestations of stress or anxiety of students. Research
has indicated that many students experience stress associated with academic pressure and
44
adjustment to a new environment which may manifest as depression or anxiety, leading to
mental distress and negative impact on cognitive functioning and effective learning
(Saipanish, 2003). First year medical students have been shown to experience high levels of
anxiety and depression, which may influence the sensitivity of measures of EI to fluctuating
circumstances. In this review, no study considered the mediating effects of well-being on EI
measurement, a confound which could potentially alter results. It is therefore essential that, in
order to for accurate measurement of EI, tools must be sensitive, generalisable and validated,
to allow for adequate determination of baseline attitudes, motivation, EI, measures of well-
being and other confounding factors. Further research should also consider the mediating
effects of high EI on susceptibility to stress, anxiety and depression, if any.
In order for EI to be a type of intelligence, it must meet three criteria, one of which being that
it must develop with age and experience, a concept shown by Mayer et al. (Mayer et al.,
1999). Goleman (Goleman, 1995) also hypothesised that EI can be learned, and improves
with age, as do Salovey and Mayer, alongside suggesting that emotional knowledge and skills
can be enhanced and learned with time. In contrast to these findings, the only study to assess
empathy longitudinally ((Craig, 1992); 3 year follow up) showed a decline in empathy over
time, post-intervention. The results of this analysis also show no difference in the outcomes
of the educational interventions with regards to the age of the participants or their year of
medical school. Importantly, of the fourteen studies included in this review, only five studies
(Evans et al., 1993, Fernandez-Olano et al., 2008, Fletcher et al., 2009, Holm and Aspegren,
1999, Shapiro et al., 2004) used a control group to assess the effects of the intervention used.
As EI has been found to increase with age, the inclusion of control groups may help to
establish the effectiveness of interventions. It is possible that any reported change in EI from
pre- to post-intervention may simply be due to the time elapsed between measurement points,
45
and not due to the success (or otherwise) of an intervention. Having a matched group of
participants who do not receive the intervention would control for any potential increases in
EI, not due to the success of the intervention, over time.
Studies also reported variations in the number of participants studied. Due to the diversity of
the study settings, dissimilarity in participant numbers is to be expected, but percentage
completion rates vary from 24% (Shapiro et al., 2004)to 93% (Winefield and Chur-Hanswn,
2000), with participant numbers also varying greatly, from 240 (Holm and Aspegren, 1999)
to 15 (Craig, 1992). Method of selection also varies, from self-selecting students to
randomised groups. Self-selecting students may have different characteristics than students
chosen randomly to participate. Given the nature of EI, it is possible that self-selecting
students may be more motivated to respond, more assertive, and generally may score higher
on the intrapersonal dimension of EI than those who may not respond to requests for
participants. This may leads to a polarization of responses, thus jeopardising the
generalisability of findings.
In addition to the above limitations, no study considered the input of students in determining
content or delivery of the educational interventions. No study considered attitudes or personal
values of medical students as a basis for the development of the intervention, tailored for that
particular student group, a pre-requisite for some interventions to be successful (Burgers et
al., 2002, Grol et al., 1998). In a similar vein, no study assessed motivation of medical
students as a contributing factor to the success of the educational interventions, regardless of
the format of the education or the emphasis, such as communication skills. It has been
hypothesised that motivation alone may have a substantial effect on the success of
educational interventions when the topic is of low interest (Foy, 2002). Differences in
motivation between participants may affect results, although this may be difficult to identify.
46
In addition, considerations of how emotional intelligence and empathy training may be
translated and applied by medical students were not reported.
Implications for future research design
Difficulties in between-study comparisons have been apparent when performing this review.
In order to alleviate this problem and allow for future reviews to investigate and clarify
factors relating to the effectiveness of delivery of education within healthcare, several
implications for research must be taken from these findings.
Adequate group sizes are needed, with groups being large enough to measure the relatively
small effects of each educational component with adequate specificity and accuracy.
Reporting and performing of both allocation of concealment and adequate blinding must be
implicit to allow for comparisons both within group and across studies. Sensitive,
generalisable and validated measures are needed to allow for adequate determination of
baseline knowledge, attitudes, motivation and behaviour of healthcare workers, and for
comparisons post-intervention. Before and after measurements are required, with sufficient
follow-up periods to ensure longitudinal stability in results. More within-study comparisons
of conflicting modes of educational delivery are needed, in future research.
Researchers need to reach a consensus as to one measure of EI, rather than the generality of
surveying the diverse range that this study attempted to investigate. That is not to say that one
model would suit every situation, nor that EI should be only be conceptualised and measured
using a rigid framework. Rather, the approach to measuring EI should be rooted in a
theoretical framework, focus on the needs of the researcher and the desired outcomes, yet
provide comparable, valid and reliable data that can be accurately compared to others’
findings.
47
These limitations and implications should be taken into account when interpreting the
findings of this review.
Conclusions and future research
This review’s findings suggest that self-reported emotional intelligence can be improved in
medical students through structured educations sessions, although this improvement may not
translate into behavioural change. However, improvements reported were small, and
therefore further research must not make the assumption that interventions can improve
emotional intelligence. More research in this area is necessary to assess if emotional
intelligence can indeed be improved through structured teaching sessions. Taking this
review’s limitations into consideration, the findings of this work have several implications for
further research in the area, as well as for current undergraduate medical education.
As mentioned previously, research has identified the importance of interpersonal EI (such as
empathy) in patient encounters, with increasing recognition of the importance of
intrapersonal EI, particularly when dealing with stress (Slaski and Cartwright, 2002). EI has
been suggested as a means of assessing levels of professional competence within the
affective/moral dimension (Epstein and Hundert, 2002). EI, as a construct, can easily be
mapped onto Hilton and Slotnick’s (Hilton and Slotnick, 2005) six domains of
professionalism, with intrapersonal skills reflecting the personal, or intrinsic, attributes of
professionals, and interpersonal skills reflecting the co-operative attributes of professionals.
The benefit, therefore, of recruiting individuals with high EI to undertake undergraduate
training is apparent.
48
Medical schools receive large amounts of applicants each year, all with uniformly high
academic achievements(Brown and Bylund, 2008). With each medical student in the UK
currently costing approximately £200,000 to train (Brown and Bylund, 2008), it is essential
that selection methods are robust and reflect the skills and attributes laid out by regulatory
bodies. In the USA, assessment of EI has been integrated as part of the selection process in
some medical schools, in an attempt to consider competency in interpersonal skills
(Carrothers et al., 2000, Elam, 2000). Despite the use of EI as a selection measure, this
review found little research conducted on improving medical students’ EI. Research at
present into improving the emotional development of medical students has mainly focused on
structured training to increase empathy, with mixed results. Only one study focused
specifically on improving medical students’ emotional intelligence (Fletcher et al., 2009),
with a small increase reported.
If the present selection process, based on cognitive ability alone, is sufficient, then it would
be valuable to consider both medical students’ entry-level EI, and to see if EI can be
improved through structured training sessions, particularly given research suggesting the
importance of EI in medicine (Lewis et al., 2005). Medical students and doctors differ from
the general population in that they are required to continually engage with relationships
(patient-doctor, colleague, peers) as part of their profession, for which EI is important
(Epstein and Hundert, 2002).
Despite EI increasing with age, it may be difficult to expect to produce highly emotionally
intelligent doctors without establishing a method of admissions to reflect this criterion.
In addition, Objective Structured Clinical Examinations (OSCEs) are the current method of
assessing clinical skill performance in undergraduate medical students, as they allow for the
49
assessment of students without endangering patients’ health. Stratton et al (2005) found that
facets of EI were related to simulated patient satisfaction scores in OSCEs, indicating the
importance of evaluating EI, and its links with communication skills, within medical
education research.
This therefore raises the question: could a 5 minute mock-OSCE, whereby a prospective
student interviews a simulated patient and the quality of their communication is rated, sit
alongside the traditional entry-level interview as a means of assessing EI, empathy and
communication skills of applicants prior to selection? This approach has already been
adopted by St George’s Medical School (London, UK) for the academic year 2009/2010, as
well as being widely used in Canada since 2001 (Rosenfield et al., 2006), and takes the form
of Multiple Mini Interviews (MMI). MMI consists of eight different tasks, each lasting five
minutes, and assesses skills such as empathy, academic achievement and communication
skills. Research has indicated the MMI to be more reliable, and have better predictive power,
than traditional interviews (Rosenfield et al., 2006), but, being a relatively new concept, more
time is needed before the effects of this selection process can be seen on medical practice.
What is evident, however, is that little research has been conducted on improving the EI of
medical students during undergraduate medical education. This makes synthesis of the effects
of interventions on EI difficult. In addition, no research that the authors are aware of has
looked at the effects of EI interventions on examination performance, which would make for
valuable further research.
Future research should aim to assess the relationship between EI and objective, behavioural
outcomes, transferrable to the clinical setting, with the goal of establishing a theoretic,
observable link between EI and clinical behaviour. It can be hypothesised that EI is related
directly to the competency of interpersonal and communication skills; medical students who
50
are considered to have high EI abilities may be more sensitive to identifying and responding
to expressions of psychosocial distress when communicating with patients. It would therefore
be beneficial to evaluate the effectiveness of interventions to improve EI on the clinical
performance of medical students, for example in communication skills OSCEs. This review
provides an initial examination of the effectiveness of interventions to improve emotional
intelligence in medical students.
EI is important for medical students’ wellbeing and their clinical and professional
performance, as we wish them to be clinically engaged and offer clinical leadership in their
future role as a doctor. Therefore the impact of EI on increasing self awareness and
improving their levels of resilience, influence, adaptability and decisiveness is paramount in
their wellbeing as well as their performance as potential clinical leaders. If these aspects can
be improved, then there are clear implications not only for the students, but for the patient
and the clinical environment. Evidence from the BMA Board of Medical Education (2004)
indicates that up to eighty percent of patient complaints to disciplinary bodies are attributed
to a breakdown of communication between doctors and patients.
Research has demonstrated a relationship between effective patient-provider communication
and better treatment outcomes for patients (Stewart, 1995, Rost et al., 1989, Hickson et al.,
1994, Levinson et al., 1997, Stewart et al., 1999, Kaplan et al., 1989, Roter and Hall, 1993,
Street, 2001). Cohen et al. (Cohen et al., 2005) argue that problems with communication for
the doctor manifest in a variety of ways, such as anxiety and stress. If established
relationships can be found between EI and communication skills, then this therefore will have
an impact not only on patient care, but on the well being of the doctor. If further links can be
shown between EI and communication skills, and the interventions needed to improve
students’ EI whilst they are undergraduates, it will add to the evidence suggesting that the EI
51
of applicants be considered alongside their cognitive abilities when successfully selecting
tomorrow’s doctors.
52
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